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Community Health Diagnosis in a Tribal Hamlet-A Case Study from India

Article in Indian Journal of Public Health Research and Development · January 2019
DOI: 10.5958/0976-5506.2019.01250.6

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 DOI Number: 10.5958/0976-5506.2019.01250.6

Community Health Diagnosis in a Tribal Hamlet–A Case

Study from India

Venkitachalam Ramanarayanan1, Chandrashekar Janakiram2, Vinita Sanjeevan3, Joe Joseph4,

Bobby Antony5, Naveen Varghese6, Vineetha K6, Heljo Joseph6, Sravan Kumar Yeturu7
1
Assistant Professor, 2Professor, 3Postgraduate Student, 4Professor and Head of Department, Department
of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, AIMS, Kochi,
5
Senior Lecturer, Department of Public Health Dentistry, Royal Dental College, Chalissery PO, Palakkad;
6
Postgraduate Student, 7Assistant Professor, Department of Public Health Dentistry, Amrita School of
Dentistry, Amrita Vishwa Vidyapeetham, AIMS, Kochi, Kerala, India

ABSTRACT
This is an account of a Community Health Diagnosis program conducted in a tribal hamlet in Kerala,
,QGLD7KH JRDO RI WKH SURJUDP ZDV WR LGHQWLI\ IDFWRUV D൵HFWLQJ KHDOWK RI WKLV SRSXODWLRQ DQG GHWHUPLQH
WKHDYDLODELOLW\RIUHVRXUFHVZLWKLQWKHFRPPXQLW\WRDGGUHVVWKHVHIDFWRUV7KHSURJUDPLGHQWL¿HGWKHIHOW
needs of this marginalized population and developed a causal loop diagram to identify the social and cultural
IDFWRUVD൵HFWLQJWKHLUKHDOWK$FWLRQDEOHUHFRPPHQGDWLRQVZHUHSURSRVHGWRWKHORFDOSROLWLFDOOHDGHU,WZDV
concluded that addressing social determinants is key to delivering health care in low resource settings.

Keywords: Community health diagnosis; Social determinants; Tribal

Introduction The Community Health Diagnosis (community

India is the land of many diversities, home to
more than 1.2 billion of the world’s population, a
colossal assortment of various cultures and diversities.
The indigenous groups (tribals or adivasis as they are
ORFDOO\ DGGUHVVHG  FRQVWLWXWH DERXW  RI WKH WRWDO
population[1]. Being a marginalised and disadvantaged
community, the tribals in India face a plethora of
health issues calling for urgent attention. A burgeoning
YROXPH RI UHVHDUFK LGHQWL¿HV VRFLDO IDFWRUV DW WKH URRW
of health problems especially among the disadvantaged
groups. The Commission on Social Determinants of
Health proposed that social determinants are relevant to
communicable and non-communicable diseases alike[2].
Hence identifying of social determinants is key to
addressing most health issues.
Corresponding Author:
Chandrashekar Janakiram
Professor, Department of Public Health Dentistry
Amrita School of Dentistry, Amrita Vishwa Vidyapeetham,
AIMS, Ponekkara P.O., Kochi 682041, Kerala, India
Phone: +919481789572
Email: sekarcandra@gmail.com
health assessment) is the foundation for improving and
promoting the health of the people of a community. The
goal of community assessment is to identify factors
WKDW D൵HFW WKH KHDOWK RI D SRSXODWLRQ DQG GHWHUPLQH
the availability of resources within the community to
adequately address these factors[3]. According to the
:+2 GH¿QLWLRQ LW LV ³D TXDQWLWDWLYH DQG TXDOLWDWLYH
description of the health of citizens and the factors which
LQÀXHQFH WKHLU KHDOWK ,W LGHQWL¿HV SUREOHPV SURSRVHV
areas for improvement and stimulates action”[4].
It starts with collecting basic data about community
beginning from geographical characteristics of the
community, to analysing the health condition of its
LQKDELWDQWV WKHUHE\ SUHVHQWLQJ DQ RYHUDOO SUR¿OH RI WKH
community. The World Health Organization endorses
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physical, mental and social well-being and not merely
WKHDEVHQFHRIDQ\GLVHDVHRULQ¿UPLW\[5].
Purpose of community diagnosis
z To act as a tool to bring out the hidden issues that
are not tangible to the community or policy makers
EXWDUHGLUHFWO\RULQGLUHFWO\D൵HFWLQJWKHLUKHDOWK
 124 Indian Journal of Public Health Research & Development, June 2019, Vol.10, No. 6
z To reach out to underprivileged people who are
unable to utilize the available facilities due to
poverty, prevailing discriminations or other social
causes.
z To determine genuine problems of the community,
that the community itself may not have perceived
as problems.
z To suggest priority areas for intervention and
solutions for the same.
z To identify and communicate these problems from
the local level to the state and national level.
z To serve as baseline data for assessing the
H൵HFWLYHQHVV RI DQ\ LQWHUYHQWLRQ RU SURJUDP
implemented.
z $SSUDLVLQJ WKH ¿QGLQJV WR SROLF\ PDNHUV ZKR LQ
turn can implement the suggested solutions for
community betterment. This process is better
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public health professional.
It should be understood that community diagnosis
LVQRWDRQHWLPHD൵DLUUDWKHUDFRQWLQXRXVDQGG\QDPLF
process. It requires constant monitoring and follow-up to
HQDEOHVLJQL¿FDQWFKDQJHVLQWKHFRPPXQLW\
As mentioned earlier, there is a need to dispel the
myth that ill-health is merely caused due to bio-medical
reasons. The advancements in medical technologies
and advent of super-specialties have cocooned medical
professionals to the four walls of a hospital. Community
diagnosis program provides an opportunity to sensitize
PHGLFDOSURIHVVLRQDOVWRGLDJQRVHWKHH[DFWµFDXVH¶RID
GLVHDVHE\UHÀHFWLQJRQWKHVRFLDOFXOWXUDODQGHFRQRPLF
aspects of a disease/illness as well.
Community diagnosis programs has been
successfully implemented in many countries as a part
of routine medical curriculum[6-8]. This training in early
years of medical education could have a wider impact in
shaping the thought process of the professional.
Community health diagnosis program in a tribal
hamlet in Wayanad, Kerala
Need for the program: The purpose of this program
was to highlight the view health needs and problems
cannot be viewed in isolation. It has been observed that
in deprived communities, health is often not a priority.
An approach to identify their felt needs and addressing
them becomes vital in improving their general health.
Hence, a community health diagnosis program was
designed and implemented to identify the key social and
cultural factors governing health related behaviour of a
tribal community in the state of Kerala, India
Methodology
Information was elicited through primary data
availed from household surveys in the form of structured
interviews, group discussions and analysis of health
care providers, community leaders and community
representatives’ perspectives and from secondary data
(previous studies, newspaper reports and government
publications).
A total of 28 houses belonging to Madakunnu
tribal colony were surveyed by a nine member team
comprising of faculty and postgraduates scholars of
Public Health Dentistry, Amrita School of Dentistry.
Health care providers of two hospitals frequented by
tribals were interviewed.
As an attempt to orient and improve their attitudes
towards basic hygiene and sanitation, households were
provided with a basic health kit consisting of bathing
soap, toothpaste and toothbrush, shampoo, band-aids
and nail clippers.
Findings
&RPPXQLW\ SUR¿OH Madakunnu is a tribal hamlet in
the hilly regions of Wayanad district in Kerala. The
geography of the hamlet is presented in the form of a
social map (Figure 1) developed with the help of a
preceptor. Social map is a two-dimensional cartographic
representation showing relative households and social
institutions.
 Indian Journal of Public Health Research & Development, June 2019, Vol.10, No. 6
Figure 1: Social mapping of Madamkunnu tribal hamlet
Community characterization: We found that on an
DYHUDJH ¿YH SHUVRQV OLYHG WRJHWKHU LQ D VLQJOH URRP
kuchha house. Majority of them were manual labourers
working for daily wages in nearby agricultural lands
drawing a remuneration of Rs 400 (for men) and Rs
250 (for women) per day. They usually worked for a
maximum of 10 days per month. Literacy rates were
found to be poor with most of the females educated upto
4th grade and males till 8th grade of schooling.
Prioritization: Identifying felt and normative needs
required weighing and prioritizing the various
community problems. The following observations were
made in the process.
Fever and cough were the common health issues
expressed by the community for which care was sought
from a nearby government primary health center and
two charitable hospitals. From the health provider’s
perspective, tuberculosis, under-nutrition and anaemia
were the most common health issues. This could
predominantly be attributed to their living conditions
like poor housing, overcrowding, lack of potable water
DQG LQKDODWLRQ RI ¿UHZRRG IXPHV &RQVXPSWLRQ RI
125
the alcohol and use of tobacco were the other major
SUREOHPVD൵HFWLQJWKLVFRPPXQLW\
7KHIRUHPRVWEDUULHUVLQVHHNLQJFDUHZHUHGL൶FXOW\
in reaching the health care facility during need due
to rough terrain, poorly motorable roads, lack of
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&RPPXWLQJ ZDV GL൶FXOW LQ WKH GDUN DQG GXULQJ UDLQ\
seasons. Lack of electricity compounded the problem
leading to a situation where sick and needy were left to
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The primary concern was housing. Roofs built of
hay and plastic sheets gave way during rainy seasons
leading to perennial leaks and dampness and associated
illnesses like fever and infectious diseases. The problem
of overcrowding in a single room house, cooking using
¿UHZRRG LQ WKH VDPH URRP DQG ODFN RI YHQWLODWLRQ
were aggravating factors for development and spread
of infections. The other concern raised was the lack of
potable water. Majority of the households drew water
from a man-made pit on the river bank. This pit was
not covered and exposed to a variety of litter and debris
D൵HFWLQJ WKH TXDOLW\ RI ZDWHU %RLOLQJ RI ZDWHU EHIRUH
 126 Indian Journal of Public Health Research & Development, June 2019, Vol.10, No. 6
consumption was practiced only during rainy seasons.
Community leaders and doctors opined that awareness
levels regarding health and disease were generally poor.
'HWDLOHG DQDO\VLV RI WKH LGHQWL¿HG SUREOHPV The
foremost objective of a community diagnosis program
is to view health from a wider perspective. One of
the methods to obtain a comprehensive picture is
by developing a causal loop model. It is a model to
understand the complex systemic nature of health and
LGHQWLI\NH\YDULDEOHVD൵HFWLQJLW
Figure 2: Causal loop diagram
Actionable Recommendations: The following
recommendations were proposed:
1. Improving access to health care by converting the
present rough terrain paths to motorable roads.
2. Provision of electricity atleast in the form of
public lighting source (like street lamps and high
mast lights).
3. To address the problem of respiratory infections
and TB, provision of LPG cylinders as a part of
ongoing central government schemes is suggested.
At the end of data collection, a brain storming session
was conducted among the investigators to develop a causal
loop diagram from data obtained during household visits,
RQ¿HOG REVHUYDWLRQV DQG H[SHUW RSLQLRQ IURP YDULRXV
VWDNHKROGHUV.H\YDULDEOHVZHUHLGHQWL¿HGUHODWLRQVKLS
of one variable to others was established and in the event
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PDMRULW\ YRWH 7KH ¿QDO GLDJUDP ZDV GHYHORSHG XVLQJ
Vensim software (Figure 2).
Continued emphasis on education and initiation of
sustainable health programs was highly recommended
as a long term strategy. Over a period of time, this
could translate into the creation of skilled labourers and
widening the scope of employment opportunities. These
recommendations, if implemented, could have a positive
impact on the health and overall development of this
marginalised community.
Advocacy: The report of the program was handed over
to Member of Legislative Assembly (MLA) of the
constituency to appraise the actionable changes who
DVVXUHGWRORRNLQWRWKH¿QGLQJV
 Indian Journal of Public Health Research & Development, June 2019, Vol.10, No. 6
Conclusion
There is a constant tussle between the normative
need from a health professional’s perspective and the felt
needs of a marginalized community. Though medicine has
seen rapid strides in terms technological advancements
and treatment modalities, it has not translated into better
health outcomes especially in disadvantaged populations.
So, it can be argued that it is the non-medical factors
like social and economic environment that increase the
vulnerability to diseases. There is a poor realization on
the part of health professionals to think beyond bio-
medical reasons to ensure optimum health.
Addressing health disparities requires an upstream
approach. It is obvious that addressing poverty and other
social determinants will ensure improvement in health
outcomes. Unless these determinants are addressed,
improving access and providing health care through
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substantially reduce the burden of diseases.
Thus, through community health diagnosis, we
call for a change in approach to tackle health problems
through the lens of social determinants.
Source of Funding: This community diagnosis program
was conducted and funded as a part of tribal outreach
initiative of Amrita Institute of Medical Sciences, Kochi,
Kerala
Ethical Clearance: The program was approved by the
management of Amrita Institute of Medical Sciences,
Kochi, Kerala.
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